service requirements

A PCN has four key functions:

a) co-ordinate, organise and deploy shared resources to support and improve resilience and care delivery46 at both PCN and practice level;
b) improve health outcomes for its patients through effective population health management and reducing health inequalities;
c) target resource and efforts in the most effective way to meet patient need, which includes delivering proactive care; and
d) collaborate with non-GP providers to provide better care, as part of an integrated neighbourhood team.

1. Supporting and improving resilience and care deliveryA PCN must work with, and support, its Core Network Practices to improve the quality and effectiveness of its delivery of the Network Contract DES, whether components are delivered at PCN or practice level.  To achieve this, the PCN must continuously work to improve patient experience and the care that patients receive. This involves ensuring effective allocation of funding and Additional Roles Reimbursement Scheme capacity across the PCN as well as supporting the effective configuration of practice capacity. It also involves supporting the application of peer-review and continuous improvement techniques across Core Network Practices.

2. Improving health outcomes and reducing health inequalities
A PCN must seek to improve health outcomes for its population using a data-driven approach and population health management techniques in line with guidance and the CORE20PLUS5 approach.  The approach must include, but is not limited to, the following activities:

a) use of insightful analytics, alongside improved data recording and use (including ethnicity), to target care and improve outcomes in populations groups where there is greatest opportunity;
b) working with partners, including community pharmacy, to proactively identify and manage CVD risk, hypertension and raised lipids in line with nationally agreed guidance and pathways;
c) reviewing cancer referral practice in collaboration with partners and working to improve early diagnosis; and
d) working with partners to improve screening uptake, inclusive of breast, bowel and cervical cancer.

A PCN should actively seek to reduce health inequalities across its Core Network Practices in line with guidance and the CORE20PLUS5 approach. To address health inequalities, a PCN should work in partnership within local communities to deliver effective outreach and target care to address health inequalities that are amendable to primary care intervention.

3. Targeting resource and efforts
A PCN must contribute to the delivery of multi-disciplinary proactive care for complex patients at greatest risk of deterioration and hospital admission, by risk stratifying patients and offering care in accordance with the guidance. This must be done as part of INTs, with the aim of reducing avoidable exacerbations of ill health, improving quality of care and patient experience, and reducing unnecessary hospital admission.

Other key requirements of a PCN are to:
a) detail the measures a PCN will take to improve medicines optimisation and implement those measures, including ensuring medicines management and use of Structured Medication Reviews for high-risk cohorts, as specified in the Guidance. This should include medicines optimisation strategies for reducing polypharmacy, minimising risk of prescribing harm, reducing over-prescribing and managing the risk of dependency on prescription drugs;
b) provide access to a social prescribing service to those who may benefit, so as to help meet the practical, social and emotional needs that can otherwise affect health and wellbeing; and
c) deliver an Enhanced Health in Care Homes service in accordance with the framework and guidance including

I. agreement with the commissioner for which care homes the PCN is responsible;
II. identifying a lead GP (or other senior clinician) with responsibility for implementation of the EHCH framework for the agreed care homes, and to provide continuity of medical care;
III. co-ordinating an MDT meeting and associated actions, including the lead GP or clinician and care home staff;
IV. delivering a weekly care home round; and
V. ensuring accurate coding of care

4. Collaboration with non-GP providers to provide better care
A PCN must work with other PCNs, local community services providers, mental health providers, community pharmacy providers and other relevant health and social care delivery partners in the best interests of patient care. This includes developing and fostering strong relationships with other clinical leaders and commissioners to successfully manage the health and care needs of the populations they serve.

A PCN must provide enhanced access between the hours of 6.30pm and 8pm Mondays to Fridays and between 9am and 5pm on Saturdays.

A PCN must 

• provide bookable clinical appointments that 
  • are available to all PCN Patients
  • are for any general practice services and services pursuant to the Network Contract DES
  • are available a minimum of two weeks in advance
  • are delivered by a multi-disciplinary team of healthcare professionals
  • are a mixture of in person face to face and remote (telephone, video or online) appointments
  • are in locations that are convenient for the PCN’s patients to access in person face-to-face services
  • ensure GP cover during the Network Standard Hours

A PCN must 

• provide a minimum of 60 minutes of appointments per 1,000 PCN adjusted patients per week
• make the Network Standard Hours appointment book accessible to the Core Network Practices
• make same day online booking for available routine appointments where no triage is required up until as close to the slot time as
  possible
• operate a system of enhanced access appointment reminders
• provide patients with a simple way of cancelling enhanced access appointments at all times
• make available to NHS111 any unused on the day slots during the Network Standard Hours from 6.30pm on weekday evenings and between 9am-5pm on Saturdays, unless it is agreed with the commissioner that the timing for when these unused slots are made available is outside of these hours
• have in place appropriate data sharing and, where required data processing arrangements
• actively communicate availability of these enhanced access appointments to their patients

A PCN must 

• use appropriate tools to identify and prioritise the PCN’s Patients who would benefit from a structured medication review
• offer and deliver a volume of SMRs determined and limited by the PCN’s clinical pharmacist capacity
• ensure invitations for SMRs provided to patients explain the benefits of, and what to expect from SMRs
• clearly record all SMRs within GP IT systems
• work with community pharmacies to connect patients appropriately to the New Medicines Service which supports adherence to newly prescribed medicines
• actively work with its CCG in order to optimise the quality of local prescribing of
  • antimicrobial medicines
  • medicines which can cause dependency
  • metered dose inhalers, where a lower carbon device may be appropriate
  • nationally identified medicines of low priority

• The cohort must include patients
  • In care homes
  • with complex and problematic polypharmacy
  • on medicines commonly associated with medication errors
  • with severe frailty, who are particularly isolated or housebound patients, or who have had recent hospital admissions and/or falls
  • using one or more potentially addictive medications from the following groups: opioids, gabapentinoids, benzodiazepines and z-drugs

A PCN must

• have agreed with the commissioner the care homes for which the PCN will have responsibility
• have in place with local partners a simple plan about how the Enhanced Health in Care Homes service will operate
• support people entering, or already resident in the PCN’s Aligned Care Home, to register with a practice in the aligned PCN
• ensure a lead GP (or GPs) with responsibility for these Enhanced Health in Care Homes service requirements is agreed
• work with community service providers and other relevant partners to establish and coordinate a multidisciplinary team
• have established arrangements for the MDT to enable the development of personalised care and support plans
• have in place established protocols between the care home and with system partners for information sharing, shared care planning, use of shared care records, and clear clinical governance
• deliver a weekly ‘home round’

• In delivering the round, the PCN must
  • prioritise residents for review according to need based on MDT clinical judgement and care home advice
  • have consistency of staff in the MDT
  • include appropriate and consistent medical input from a GP or geriatrician
  • use digital technology to support the weekly home round and facilitate the medical input

• In developing support plans, the PCN must
  • aim for the plan to be developed and agreed with each new patient within seven working days of admission to the home and within seven working days of readmission following a hospital episode
  • develop plans with the patient and/or their carer
  • base plans on the principles and domains of a Comprehensive Geriatric Assessment including assessment of the physical, psychological, functional, social and environmental needs of the patient including end of life care needs where appropriate
  • draw on existing assessments that have taken place outside of the home and reflecting their goals

A PCN must

• review referral practice for suspected and recurrent cancers, and work with its community of practice to identify and implement specific actions to improve referral practice, particularly among people from disadvantaged areas where early diagnosis rates are lower
• work with local system partners to agree the PCN’s contribution to local efforts to improve uptake in cervical and bowel NHS Cancer Screening Programmes and follow-up on non-responders to invitations
• focus on prostate cancer to develop and implement a plan to increase the proactive and opportunistic assessment of patients for a potential cancer diagnosis in population cohorts where referral rates have not recovered to their pre-pandemic baseline
• review use of non-specific symptom pathways, identifying opportunities and taking appropriate actions to increase referral activity
• adopt and embed
  • the requesting of FIT tests where appropriate for patients being referred for suspected colorectal cancer
  • the use of teledermatology to support skin cancer referrals

A PCN must

• provide the PCN’s Patients with access to a social prescribing service

A PCN must

• improve diagnosis of patients with hypertension
• undertake activity to improve coverage of blood pressure checks, by
  • increasing opportunistic blood pressure testing where patients do not have a recently recorded reading
  • undertaking blood pressure testing at suitable outreach venues
  • working pro-actively with community pharmacies to improve access to blood pressure checks, in line with the Community Pharmacy Blood Pressure Check Service

A PCN must

• improve the identification of those at risk of atrial fibrillation
• identify patients at high risk of Familial Hypercholesterolaemia and make referrals for further assessment where clinically indicated
• offer statin treatment to patients with a QRISK2&3 score >= 10%
• support the earlier identification of heart failure (HF), through building awareness among PCN staff around the appropriate HF diagnostic pathway, and early identification processes for HF including the timely use of N-terminal pro B-type natriuretic peptide (NTProBNP) testing

A PCN must

• undertake network development and quality improvement activity to support CVD prevention including
  • reviewing outputs from CVD intelligence tools and sharing key learning amongst PCN staff
  • supporting the development of system pathways for people at risk of CVD through liaison with wider system partners
  • collaboration with commissioners to improve levels of diagnostic capacity for ‘ABC’ testing, including availability of ambulatory blood
    pressure monitors (ABPMs) and electrocardiogram (ECG) monitors
  • ensuring processes are in place to support the exchange of information with community pharmacies, including a process for
    accepting and documenting referrals between pharmacies and GP practices for the Community Pharmacy Blood Pressure Check Service

A PCN must

• identify and include all patients with a learning disability on the learning disability register, and make all reasonable efforts to deliver an annual learning disability health check and health action plan for at least 75% of these patients who are aged over 14
• record the ethnicity of all patients registered with the PCN
• appoint a lead for tackling health inequalities within the PCN
• review its identification of a population within the PCN experiencing inequality in health provision and/or outcomes, and ensure there is a plan to tackle the unmet needs of that population

A PCN and commissioner must have jointly

• utilised available data on health inequalities to identify that selected population, working in partnership with their ICS, including local medical or pharmaceutical committees, and local authority commissioners
• held discussions with local system partner organisations who have existing relationships with the selected population to agree an approach to engagement
• held engagement with the selected population to understand the gaps in, and barriers to their care
• defined an approach for identifying and addressing the unmet needs of this population

A PCN must

• contribute to ICS-led conversations on the local development and implementation of Anticipatory Care

A PCN must

• review its targeted programme to proactively offer and improve access to social prescribing to an identified cohort with unmet needs
• review its sample audit of the PCN’s Patients’ current
  experiences of shared decision making through use of a validated tool and its documenting of its consideration and implementation of any improvements to SDM conversations made as a result